Infectious disease guidance for health-care providers

Find information on new and emerging infectious and communicable diseases see below.

Anaplasmosis, also known as human granulocytic anaplasmosis (HGA), is a disease caused by the bacterium Anaplasma phagocytophilum. It is transmitted to humans by the blacklegged tick.

Based on recent tick-related surveillance and disease data, there is an emerging risk of anaplasmosis infection in the Southeast Public Health area.

Maintain a high level of clinical suspicion for anaplasmosis and other tickborne diseases in cases of non-specific febrile illness of unknown origin, particularly during spring and summer months when ticks are most active. Early recognition and presumptive treatment are important to prevent severe illness.

Symptoms

  • Anaplasmosis typically causes an acute febrile illness.
  • Most people will have mild or moderate illness, though severe illness and death are possible.
  • Signs and symptoms typically begin within five to 14 days after the bite of an infected tick.

Early illness

Signs and symptoms commonly seen in the first few days of illness (days one to five) include:

  • fever, chills, rigors
  • severe headache
  • malaise
  • myalgia
  • gastrointestinal symptoms (nausea, vomiting, diarrhea, anorexia) in about 20 percent of cases

Late illness

If treatment is delayed and anaplasmosis is allowed to continue, the disease may become severe.

Severe illness is rare, but may involve:

  • renal or respiratory failure
  • peripheral neuropathies.
  • disseminated intravascular coagulation (DIC)-like coagulopathies
  • rhabdomyolysis
  • hemorrhage

Rarely reported symptoms

  • Rash (occurs in less than 10 percent of cases) in patients with anaplasmosis. The presence of a rash might indicate a co-infection with Lyme disease.
  • Nervous system involvement (e.g., meningoencephalitis, focal paralysis, etc.).

Clinical course

Progression of the disease varies greatly from person to person. Patients who are treated early may recover quickly, with outpatient treatment with oral antibiotics. Those who experience a more severe course might require intravenous antibiotics, prolonged hospitalization, and intensive care.

Risk factors for severe disease include:

  • delayed treatment
  • older age
  • immune compromising conditions (e.g., advanced HIV, persons receiving chemotherapy, and other immune suppressing medication)

Testing

In Ontario, laboratory testing for anaplasmosis is performed by Public Health Ontario Laboratory. Diagnostic testing includes both molecular (PCR) and serologic methods.

PCR is the preferred method for detection of Anaplasma phagocytophilum during the acute phase of illness, as it provides the most direct evidence of active infection.

Health-care providers should also review routine laboratory investigations when assessing suspected anaplasmosis. A complete blood count (CBC) and chemistry panel can provide supportive diagnostic information.

Common laboratory findings may include:

  • mild anemia
  • thrombocytopenia
  • leukopenia (including relative and absolute lymphopenia and a left shift)
  • mild to moderate elevations in hepatic transaminases

Abnormal laboratory findings can appear within the first week of illness. However, normal laboratory results do not exclude infection and should not delay clinical decision-making when suspicion remains high.

For detailed test information, including specimen requirements, acceptance criteria, and submission guidelines, please refer to:

Treatment

Treatment for suspected anaplasmosis should not be delayed pending results of serology. Treatment is more likely to be effective if started early in the course of the disease.

Doxycycline is the first line treatment for patients of all ages.

Reporting information

Suspected and confirmed cases of anaplasmosis, whether clinically diagnosed or laboratory confirmed, are reportable to Public Health under the Health Protection and Promotion Act. To report a disease or for more information, please visit:

Resources

Post-exposure prophylaxis

The Southeast Public Health area has been identified as a high-risk area for blacklegged ticks.

Consider post-exposure prophylaxis following blacklegged tick bites when the following conditions are met:

  • the tick is a blacklegged tick, and
  • it is fully or partially engorged, or has been attached for 36 or more hours, and
  • it has been less than or equal to 72 hours since the tick was removed, and
  • doxycycline is not contraindicated.

Counsel all patients to monitor for the signs and symptoms of early tickborne illness.

Early diagnosis and proper antibiotic treatment of Lyme disease is important for best outcomes.

Treatment and management

For treatment therapy regimens, please consult the following clinical practice guidelines:

Serological testing

Find testing guidelines on Ontario’s Public Health Laboratories website Lyme Disease – Serology, and a downloadable general test requisition.

Note: If European Lyme disease testing is required, provide a travel history and request testing for European Lyme disease. Specimens are sent to the National Microbiology Laboratory for antibody testing.

Interpretation of two-tiered test results:

Note: Diagnostic testing of patients presenting with EM lesions is not recommended due to insensitivity of serologic testing during this acute stage of infection.

Antibodies normally persist in the blood for months or even years after the infection is gone; therefore, serologic testing cannot be used to determine cure or reinfection.

General laboratory findings for Lyme disease include:

  • elevated erythrocyte sedimentation rate
  • mildly elevated hepatic transaminases
  • microscopic hematuria or proteinuria

Reporting

Suspected and confirmed cases of Lyme Disease, whether clinically diagnosed or laboratory confirmed, are reportable to public health under the Health Protection and Promotion Act.  To report a disease or for more information, please visit:

Resources

Patient resources

Although measles cases have been rare in Ontario, an increase in global measles activity has resulted in an increase in reported cases of measles. Ontario is currently experiencing a multi-jurisdictional measles outbreak.

Given the current prevalence of measles in Ontario, Southeast Public Health encourages health-care providers to take the following actions:

  • Review Public Health Ontario’s Measles: Information for Health Care Providers. This document provides detailed recommendations on immunization, clinical presentation, diagnosis and infection prevention and control (IPAC) recommendations.
  • Ensure you and your staff have up-to-date immunizations and are fit-tested for a respirator. It is recommended that a fit-tested, seal-checked N95 respirator is used by health-care providers, regardless of their presumptive immune status, while providing care to individuals with suspected or confirmed measles.
  • Consider measles as a differential diagnosis. Health-care providers are strongly encouraged to consider measles as a part of the differential diagnosis when clients present with:
    • febrile illness and rash
    • history suggesting they are not immune to measles
    • history of travel to areas with measles outbreaks or that are known to have had an epidemiologic link to a measles case our outbreak
  • Ensure appropriate testing for measles. It is essential to complete ALL of the following tests to confirm a measles diagnosis:
    • nasopharyngeal swab/aspirate or throat swab for PCR
    • blood specimen for serology
    • clean catch urine for PCR
  • Report suspected or confirmed cases to public health. Do not wait for laboratory confirmation. Timely reporting of measles cases is essential to controlling the spread of illness in the community and is required in accordance with Ontario Reg 135/18 and amendments under the Health Protection and Promotion Act, R.S.O. 1990.
    • During regular business hours, health-care providers must call 613-966-5500, extension 349.
    • For after-hours, health-care providers must call 613-966-5500 and follow the prompts to reach the after-hours service.

Frequently asked questions

Can primary care settings collect specimens for mpox testing?

Yes, primary care settings can collect specimens for mpox testing.

What precautions are required to safely collect specimens?

An AIIR is not required for specimen collection for mpox testing. A single-patient room with the door closed is recommended.

Healthcare workers collecting specimens should wear the following PPE:

  • Gloves.
  • Gown.
  • Eye Protection (e.g., face shields, glasses, or safety goggles).
  • Fit-tested and seal checked N-95 respirator (or equivalent).

View PHO’s IPAC Recommendations in Health Care Settings for more information.

How are specimens collected?

Comprehensive specimen collection guidance can be found on Public Health Ontario’s website.

In patients with skin lesions that can be swabbed or have skin lesion material that can be submitted for testing, this is the preferred specimen type.

In patients with suspected Mpox virus infection who do not have a skin rash (e.g. a close contact of a case with a febrile illness but no rash) or their skin can’t be reliably swabbed (e.g. macular or popular rash only), blood should be submitted along with an NP or throat swab.

How are specimens transported?

Effective June 2, 2022, Transport Canada temporarily reclassified mpox virus as a Category B infectious substance for land transport. Mpox specimens can be transported in the same way as other Category B infectious substances your practice might be sending for testing (e.g. STI testing). In addition to the routine Category B requirement, the outer packaging must be marked, on a contrasting background with « TU 0886 ».

For full details on packaging and transporting, please view temporary certificate TU 0886: Mpox samples from the Government of Canada.

How are confirmed, probable or suspect mpox cases reported to public health?

Confirmed, probable or suspect mpox cases can be reported to public health by completing the Ontario Mpox Reporting Tool for Clinicians and faxing it to Southeast Public Health. Please note that only page one is required to be completed for reporting. Mpox case definitions can be found on page two of this document.

Mpox antiviral guidance for health-care providers

Ontario continues to monitor for cases of mpox and is working collaboratively with health care providers, Public Health Ontario (PHO), and the Public Health Agency of Canada (PHAC) to address health risk(s). Mpox Antiviral Guidance for Health Care Providers provides basic information only.

Resources

Suspect mpox algorithm for primary care

  1. Complete Public Health Ontario’s Mpox Reporting Tool (page 1 only) and fax to 613-549-0349.
  2. Notify suspect mpox patient to isolate until they receive a negative test result or they receive a call from public health.
  3. Place patient in a private room with door closed wearing a medical mask (if tolerated). Don the following PPE: gown, N95, eye protection, gloves.
  4. Does the patient have a rash that can be tested? (lesion fluid, crust material, scab, swab of lesion)
    • Yes: Collect up to 3 skin lesion specimens using a virus culture collection kit. NP/throat/blood samples are NOT needed if the patient has a rash that can be sampled.
    • No: Collect an NP or throat swab using a virus respiratory collection kit, and collect a blood sample using a red topped tube (≥5ml).
  5. Label specimen tubes: patient full name, date of collection and a unique identifier (DOB or HCN).
  6. Place sample in a biohazard bag.
  7. Complete Public Health Ontario’s General Test Requisition and place in the back fold of the sealed biohazard bag.
  8. Place specimens for transport in the appropriate transport bag for ‘Biological Substance Category B’. Mark the transport bag with « TU 0886 ».

Rabies is spread through the saliva of an infected animal via a bite, or if the saliva is introduced into a person’s mouth, nose, eyes, open cut, sore or wound.

All potential rabies exposures, animal bites and scratches, must be reported to Southeast Public Health. A Public Health Inspector will complete an investigation to ensure the victim was not exposed to the rabies virus at the time of the bite or scratch.

Initiation of rabies post-exposure prophylaxis must be reported to Southeast Public Health.